30937 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO, '�O
BUILDING DIVISION .APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
937
BUILDING ADDRESS: SANITARYNO. APPLICATION.SUBMITTAL DATE
q� 2_3--9.7
WNER:S NAM PHOW, - CONT C'TOR'S NAME " LIC NO:
� - - ��: L>` NIC CONTROLN ,
ARCHITECT/P,NGINE LIC NO: - .AD ESS e I ;'i o
r
CONTACT -P NE:- BUILDING PERMIT INFO
❑
Canal Fees Paid by Applicant(Initial) BLDG - ELECT PLUMB- MECH
❑ ❑ ❑
LICENSED CON ACTOR'SDECLARATION - QTY. ELECTRIC PERMIT FEE
I hereby affirm that Imo licensed under provisions of Chapter 9(commenting ]Q$DESCRIPTION
{ps�PLZ with Section 7000)of Division 3 of the Business and Professions Code,and my license is
F
00
in full force and effect. PERMIT ISSUANCE O SID KITCHEN REMODEL NTIA
�UUU.License Class Lic.A_ APPLIANCES-RESIDENTIAL ,
Rate-- Contractor ❑ADDITIONS ;}PLUMBING RE-PIPE
ARCHITECT'S DECLARATION' _ PANELS - ❑MULTI-UNIT ❑STRUCTURAL
ISI .Z O p I understand my plans shall be mod as public records ,pW MODIFICATION
0Z UP TO 200 AMPS
9.�{.E'W licensed Professional - El INTERIOR ❑CHIMNEY REPAIR
,,.) OWNER-BUILDER DECLARATION 201-IOWAMPS 'IMPROVEMENT
CQ$G a 1 hereby affirm that I am exempt from the Contractor's License Law for the OVER I000AMPS - ❑BATH REMODEUREPAIR ❑DEMOLITION
k 0- F following reams(Section 7031.5,Business and Professions Code:Any city or countySIGNS ELECTRICAL
❑OTHER
444771 W hatch requires permit construct, Ito p demolish, p y structure
priori t ante also remins the applicant for suchpermit file a signed statement SPECIAL CIRCUIT/MISC.
y
that he licensed F 11 thep i t o fth Contractor LicenseL (Chapter 9
� 0�'(cnm g lh5 n ](q0) fD 3 fth B dP f C Je)or TEMP.METER OR POLE INST. COMMERCIAL: . '
F,{y es C Nath ' pr there[ d th b ,i f the II g d pr Any ion of ❑NEW BLDG/ADDITION ❑DEMOLITION
2 Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
z Py' t more Nan five hundred dollars($500). ° TENANT - ❑FOOD SERVICE
Q1,as owner ofthe property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT.
will do the work,mil the structure is not imeodedocoffered for sold(Sec.]044,Business - El OTHER
and Professions Cush,The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES -
r property who builds or improves thereon,and who does such work himself or through
his own employees,provided that.such impmvomems are not intended or offered for NEW RESIDENTIAL ELECTR S
sale.If.however,the building or improvement is sold within one year ofcompletirs,the - SQ.FT.FLOOR AREA $/SQ.FT,
wner-htilder will have the burden of proving that he did not build or improve for par-
poseofeale.), -
❑ 1,as owner of the property,am exclusively commeting with licensed contractors r0 . TOTAL:
consumer the project(Sec.7044,Business and Professions Cod,)The Contractors Li-
rise Law does not apply N an owner of property who builds or improves Iherean,and QTY, PLUMBING PERMIT SP
who counters for such projects with a comraetods)licensed pursuant to the Conurseuods
License Law. PERMIT ISSUANCE
❑ Itmexemplinler Sea ,B&PCmr Nmsreamn
Owner Dare ALTER-DRAIN&'VENT-WATER(EA) - VALUATION'
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I lu rmhy affirm under penalty of perjury one of the following declarations:
❑I have and will chairman a Ceruificme of Consent to self-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
cation,as presided for by Section 3700 of the Labor Code,for the performance of the
work for which this Hermit is issued. FIXTURES-PER TRAP "
❑I have and will maintain Worker's Compensation insurance,as required by Section "
37W of the Labor Cade,for the performance of the work for which this Permit is issued.' GAS-EA.SYSTEM-1 INC.4 OUTLETS t
My Work is Compensa ro�tnxy ante coiner end Policy umy,�I MCGROUP s APN
Carrier. ff Policy No.:�Aj f�/ 113 •-I GAS-EA.SYSTF.M-OVER4(EAJ x
C�RTIFICATE OF EXEMPTION FROM W ORKERS' -
I „ COMPENSATION INSURANCE GREASFIINDUSTRL WASTE INTERCEPTOR
(This section need not be completed mf Ne permit is for one hundred dollars($Id(B - BUILDING DIVISION FE
unless.) FEES
PLANCHECK FEE
I eciify Nati.theperformance ofine work far which this permit is issued,Ishall SEWER-SANITARY-STORM M.20(1 PI'. -
but employ any person in any manner so as to become subject the Workers'Compen- ENERGY FEE
moon Laws of California.Date
WATER HEATER WNENT/ELECTR
O O Applicant - GRADING FEE ••
rjl NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATER SYST0,UTREATING
C•'! become subject to the Worker's Con,amstion provisions of the India,Cade,you most SOILS PEE t
I37y7 forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
P Q
CONSTRUCTION is ac ONLENDING AGENCY NEW RESIDENTIAL PLMR. SQ.FT. PAID Dare ReceiplN
U O l for by which
this
that there is a ed(Secti0n lending agency forthe perfortnwce of
t••i the work for which Nis permit is issued(Sec.31N].Civ.CJ
OU Lender's Name TOTAL.
Lenders Address TOTAL:
pW„ I certify Nat I have read this application and team that the above information is a BUILDING FE
Ir VI correct.I agree to comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE -
U Z building construction,and hereby authorize representatives of this city to onwrupat the SEISMIC FEE
above-mentioned property for inspection purposes.
(We)agree to save.indemnify and keep harmless the City of Cupertino agtinsl, PERMIT ISSUANCE ELECTRIC FEE
liabilities,judgments,costs and expenses-which may in any way accme against saiJCity ALTER OR ADDTO MECH. PLUMBING FEE
nmmenceof Nag limrlhms it.
APPLICANTngS IL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO
OVER I0,000C CFM)
MECHANICAL FEE
SO RCBR LA NS. -
%z 92 AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTIONTAX
" 9ignat of Ap ieaHAZA rZ2 Dote EXHAUST HOOD(W/DUCT) - HOUSING MITIGATION FEE
HAZARDOUS MATERIALS
eacc pa DISCLOSURE
Will
ytheCupertnr fMuni buildings,Chantstore0r handle Health and Safety HEATING UNIT(TO IOO,Ig10 BTU)
Carter defined io the Cupertino Municipal Code,Chapte[9.12,and the Health tad Safety
Section 25532(v)] HEATING UNIT(OVER 100,000 BTU), ,
❑Yes ^ [_1 No PAID
VENTILATION FAN(SINGLE RESID) Date Receipt is
Will the applicant or[more building occupant use equipment or devices which BOILER-COMP(HE OR 100,000 BTU)
emit hazardous air contaminants as defined by the Bay Arco Air Quality Management TOTAL: ,
District? BOILER-COME(OVER I W.000 BTU)
FI yes (]No �
I have read the haaNOus materials uiremems under Chapter 6.95 of the Cali- AIR CONDITIONER -
req p ISSUANCE DATE
forme Hco ne Safety Code,Sermons 25505,25533 and 25534,I understand ohm if the NEW RESIDENTIAL MECH. SQ.FT. .
building does
net currentlyentswhich have
st at cast pthatit is my responsibility Nnotifythe occupant
of the requirements which must be met prior or issuance of t Certificate of Occupancy.
Owner or authorized agent Date TOTAL: n ISSUED BY: -
OFFICE